Abstract
HISTORY: An 18-year-old senior high school football player sustained an avulsion fracture to the left 5th digit proximal phalanx on October 2018 during practice which was treated with an ulnar gutter cast for 6 weeks. He played through the remaining football season and baseball season, after which, he presented to the clinic with what he felt was instability in his left hand. He reported no new trauma. Upon examination, there was mild tenderness in the 5th digit and tenderness localized to the head of the 4th metacarpal. The patient denied numbness, weakness, swelling, or bruising to the site of pain, but endorsed clicking of the 4th digit when making a fist and opening his had again. PHYSICAL EXAMINATION: Mild Boutonierre's deformity of 5th. Full ROM with all finger motions. Snapping sensation when going from fully flexed position in 4th digit to fully flexed position. Tenderness to palpation at 5th digit PIP and at 4th digit just proximal to MCP. Slightly more movement with anterior - posterior translation of the 4th metacarpal dorsally compared to the proximal phalanx. Sensation intact to light touch. DIFFERENTIAL DIAGNOSIS: 1. Stress fracture 2.Trigger Finger 3. Dieterich’s Disease 4. Bone Contusion 5. Improper rehab from initial splint immobilization from original injury TEST AND RESULTS: X-rays: Interval healing of nondisplaced fracture of the fifth digit proximal phalanx. Cystic lesion of the head of the fourth metacarpal not evident on the comparison study. MRI: Abnormality of the 4th metacarpal head including articular surface flattening with adjacent subcortical marrow edema bordered by linear somewhat serpiginous hypointense signal, perhaps sclerosis, and with some tiny subchondral cystic foci as well. Small amount of T2 hyperintense marrow signal in the visualized distal shaft of the 4th metacarpal as well. Small 4th MCP joint effusion. FINAL/WORKING DIAGNOSIS: Dieterich’s Disease (avascular necrosis of the metacarpal head) TREATMENT AND OUTCOMES: 1.Curettage of avascular necrosis and autogenous bone graft from distal radius, internal Fixation of metacarpal with K-wire and Ulnar gutter splint 4. Removal of K-wire at 6 weeks, application of ulnar gutter OT brace. 5. Home OT with ROM and muscle strengthening exercises. 6. Formal OT. Patient regained full function of the hand and returned to sports.
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